Treatment of dental implant-related maxillary sinusitis ... · 87 Treatment of dental...
Transcript of Treatment of dental implant-related maxillary sinusitis ... · 87 Treatment of dental...
87
Treatment of dental implant-related maxillary sinusitis with functional endoscopic sinus surgery in combination with an intra-oral approach
Ki-Young Nam, Jong-Bae Kim
Department of Dentistry, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:87-90)
The present report describes the case of a patient who underwent maxillary sinusitis right after dental implant installation with sinus lifting. Computed tomography scan revealed a dental implant (#16) was protruded inside the right maxillary sinus and confirmed the obstruction of ostium. A symptom remission was gained with the dual approaches combined by functional endoscopic sinus surgery and an intra-oral approach. Fully recovered function and healing of sinus were identified after 10 months follow-up. We report the case of sinusitis caused by protrusion of implants with sinus floor lift pro-cedures and propose that practitioners should be aware of the possible its complications and management.
Key words: Maxillary sinusitis, Dental implants, Endoscopy[paper submitted 2014. 2. 28 / revised 2014. 4. 14 / accepted 2014. 4. 16]
suchasCaldwell-Lucapproach,inferiormeatalosteotomy
ororo-antralfistulaclosurehavebeenpopularoptionsforthe
treatmentofpost-opsequelae.However, these techniques
havebeeninsufficientforfullrecoveryofmaxillarysinus
function.Forcompleterecoveryofmaxillarysinusfunction
andrapidresolutionofsinusitis,functionalendoscopicsinus
surgery(FESS)isrecommended,whichisfavoredoverthe
Caldwell-Lucapproachbecauseofpositiveoutcomessuchas
shorterhospitalstayandlowermorbidity6.Wereportacase
ofmaxillarysinusitisrelatedtofailedosteotomesinuseleva-
tiontechniqueaswellassuccessfulmanagementwithFESS
incombinationwithanintra-oralapproach.
II. Case Report
A39-year-oldfemalewasreferredtoourdentaldepart-
mentduetoconsiderablepainintherightzygomaareawith
headacheintherighttemporalregion.Thepatienthadahis-
toryofextractionof#16approximately5monthspriordueto
averticalcrack,andunderwentsingledentalimplantinstal-
lationwiththeosteotometechniquefor#16inalocaldental
clinic3dayspriortopresentation.Panoramicviewrevealed
thatthesingleimplantwasprotrudingintotherightmaxil-
larysinusandtheradiopacityof thesinuswas increased.
(Fig.1)Medicaltherapywasadministered,includingempiri-
I. Introduction
Rehabilitationofmasticatoryfunctionafterdentalimplants
areplacedinthepartialorfulledentulousareahasbecome
routine;however,implantationcanoccasionallybecompro-
misedbyanatomicallimitationsaswellasthestatusofal-
veolarboneandsurroundingsofttissue.Implantationaround
theposteriormaxillaarea isoftenchallengingbecauseof
alveolarboneresorption,sinuspneumatizationorotherrea-
sons1.Toovercometheseproblems,maxillarysinuslifting
andsinusbonegraftingareoftenrecommended,although
theseprocedureshaveuncommoncomplicationssuchas
maxillarysinusitisandinfection.Inadequatemaxillarybone
thickness,alongwithpoorsurgicalplanningandlackofex-
perience,isalsoassociatedwithprotrusionofimplantsinto
themaxillarysinus2,3orgraftingmaterialmigrationtothe
paranasalsinuses(PNS)4,5.Generally, intraoralapproaches
CASE REPORT
Ki-Young NamDepartment of Dentistry, Keimyung University Dongsan Medical Center, 56, Dalseong-ro, Jung-gu, Daegu 700-712, KoreaTEL: +82-53-250-7805 FAX: +82-53-250-7802E-mail: [email protected]
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CC
Copyright Ⓒ 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.
http://dx.doi.org/10.5125/jkaoms.2014.40.2.87pISSN 2234-7550·eISSN 2234-5930
J Korean Assoc Oral Maxillofac Surg 2014;40:87-90
88
plant.(Fig.2)Itwasunclearwhetherbonegraftinghadbeen
performed.Water’sviewalsorevealedincreaseddensityand
hazinessintherightmaxillarysinus.(Fig.3)Basedonthis
evidenceofobstructionoftheostiumoftherightnasalcav-
ityandinfectionofthemucoceleoftherightmaxillarysinus,
weconsultedanotolaryngologistandconcludedthatanintra-
oralapproachalonewouldnotbesufficienttoremovethe
mucoceleandpotentiallyscatteredgraftparticles.Implant
removalwasalsoconsideredbecausethefixturewasloose;
therefore,FESSwasperformedincombinationwithanintra-
oralapproachundergeneralanesthesiafollowedbyadmis-
sionofthepatient.Theoperationwasconductedbycoopera-
tiveteamapproach,includinganoral-maxillofacialsurgeon
andotolaryngologist.Aftertheendoscopewasinsertedinto
thenose,cottonsoakedwithepinephrinewasappliedtothe
middlemeatusfor5minutes,thencottonwasremoved.The
middleturbinatewaswidelyexcisedsothatpusandinfected
bonegraftparticlescouldbeflushedfromthesinuscavity.
Theostiumwasexposedbyremovaloftheuncinateprocess
inthemiddlemeatustoaccesstoostiumandtheethmoidal
sinus.Edematous,hyperplasticnasalmucosawithinthesi-
nuswasenucleatedafterthenaturalostiumwassurgically
enlarged(Fig.4),thenthesinuswasirrigatedwithnormalsa-
lineuntilnoadditionalfree-floatingparticleswereobserved.
Duringthisprocedure,removalofthesinusmucosaofthe
maxillarywasnotattempted.Implantremovalandprimary
closureoftheoro-antralfistulawereperformed.(Fig.5)The
patientreceivedpolyvinylacetalabsorbentnasalpackingfor
calantibiotics(penicillin,clindamycin),non-steroidalanti-
inflammatorydrugs,expectorantsandantihistamines,which
wereprescribedtomitigatesymptoms;however,thepatient
showednoimprovementafter4weeksoffollow-up,andthe
persistenceofsignsandsymptomsofdiscomfortindicated
thatfurtherinvestigationwasneeded.Coronalviewcomput-
edtomography(CT)revealeddefinitesignsofsinusitiswith
opacificationoftherightmaxillarysinusaswellasethmoidal
sinus,andconfirmedthatadental implantwasprotruding
approximately5mmintothesinuswithadisplacedbone
fragmentfromthesinusfloorattheapicalportionoftheim-
Fig. 3. Water’s view computed tomography revealed increased density and haziness in the right maxillary sinus.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 1. Panoramic view taken 5 days after right maxilla sinus bone grafting and #16 implantation revealed dental implant protrusion into the right maxillary sinus.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 2. Paranasal sinuses computed tomography revealed muco-sal thickening and opacification with air bubbles in the right maxil-lary sinus and the protrusion of an implant fixture into the sinus, along with a bony fragment (arrow).Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Treatment of dental implant related maxillary sinusitis
89
ciliaryclearanceisamajorclinicalproblem.Thestagnation
ofsecretionsandobstructionofexcretionfromandventila-
tionwithinthemaxillarysinusarepredisposingfactorsforsi-
nusinfection7.Theareabetweenmiddleturbinateandlateral
nasalwalloftenhastheanatomicalvariance;therefore,ede-
maofthemucosacanresultinobstructionoftheostiumand
dysfunctionofmucociliaryfunction.Maxillarysinusfloor
1week,nocomplicationsoccurredandsymptomsimproved
graduallyoverthehealingperiod.Theradiopaquephaseof
thesinuscavitywasremarkablydecreasedintherightmaxil-
larysinus1weekpostoperatively,thoughmucosalthicken-
ingwasstillobserved.(Fig.6)However,fullrecoveryofthe
sinuswasevidencedontransversedentalCTatthe10-month
follow-upvisit.(Fig.7)
III. Discussion
Inmanycasesofmaxillarysinusitis,dysfunctionofmuco-
Fig. 4. Endoscopic view, after uncenectomy and maxillary sinus ostium enlargement.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 5. An intra-oral approach allowed for the removal of the mo-bile dental implant and closure of the oro-antra fistula.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 6. Computed tomography revealed that opacification of the right maxillary sinus was decreased 1 week postoperatively. Mu-cosal thickening of the sinus wall had also decreased.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 7. Transverse dental computed tomography scanning re-vealed complete recovery of the right maxillary sinus with normal mucosal thickness 10 months after surgery.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014
J Korean Assoc Oral Maxillofac Surg 2014;40:87-90
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sinuslifting.Dentalsurgeonsperformingsimilarprocedures
shouldbeawareofthepossiblecomplicationsthatcanarise
fromforeigndebrisinvadingthemaxillarysinus.
Conflict of Interest
Nopotentialconflictofinterestrelevanttothisarticlewas
reported.
References
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lifthasbeenreportedtocausepostoperativesinusitis8.The
elevationoftheSchneiderianmembranecouldaffectasinus
homeostasisandleadtosinusitisbytemporalobstructionof
aphysiologicalsinusdrainagethroughtheostio-meatalunit
(OMU)9.Mucosal inflammationcausedbymisplacedim-
plantscansimilarlycausemucosalinflammationandstenosis
of theOMUwithdetrimentaleffectsonsinusventilation.
Recommendedtreatmentfordentalimplant-relatedsinusitis
typicallyinvolvessurgicalrestorationforproperdrainageand
ventilationofthesinus,interruptingthedescribedsequence
ofeventsthatleadtosinusinfection.
FESSisarelativelyrecentsurgicalprocedureusedinthe
treatmentofmaxillarysinusitis.ItwidenstheOMUtofacili-
tatesinussecretionfromthePNSintothenasalcavity,asthe
patient'snormalanatomicalstructuresarepreserved10.FESS
isabletotreatOMUalterationsandremovedisplaceddental
implants, thoughitdoesnotallowforremovalofimplants
thatprotrudeintothesinus,asinthepresentcase2.Intraoral
approachesareamoresuitablemethodforaddressingoro-
antralfistulasandremovingimplantsfromwithinthesinus,
buttheycannotrepairOMUalterationsandotheraspectsof
sinusitis7.Simpleeliminationoftheirritatingstimulus,such
asexposedordisplacedimplant,couldalsobeconsidered.
Reports in the literature indicated that implantexposure
greaterthan4mmfromthesinusfloorcangiverisetosinus-
itisorrhinosinusitis11.Inthisreport,theimplantfixturewas
removedduetonotonlytheexposedlength(5mm),butalso
thesignificantlackofinitialstability.
Thoughfurtherstudiesareneededtoevaluatetheefficacy
ofFESSintreatingrecalcitrantimplant-relatedsinusitisand
itsabilitytopreventrecurrence,thecombinationofFESSand
anintra-oralapproachshouldbeconsideredausefuloption
fortherestorationofnormalnaso-sinushomeostasis2.The
authorsreportfavorableresultsofthisdualapproachinthe
treatmentofmaxillarysinusitisfollowingimplantationwith